1144598368 NPI number — ILLINOIS ACUPUNCTURE AND SPINE CLINIC IAS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144598368 NPI number — ILLINOIS ACUPUNCTURE AND SPINE CLINIC IAS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ILLINOIS ACUPUNCTURE AND SPINE CLINIC IAS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144598368
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 925
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMPSHIRE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60140-0925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-284-0787
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2401 ROUTE 20
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PINGREE GROVE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-284-0787
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/02/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BALDINO
Authorized Official First Name:
DANA
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
847-284-0787

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  038011528 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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